Employing Resistance Training as a Therapeutic Intervention for Cancer Survivors

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1 Employing Resistance Training as a Therapeutic Intervention for Cancer Survivors G. Stephen Morris, PT, Ph.D., FACSM Lisa A. Grant, PT, DPT, SCS, LAT, ATC, CSCS, CKTP Dept. of Physical Therapy Wingate University Wingate, NC Objectives 1. Describe muscle dysfunctions associated with cancer and its treatment. 2. Describe the adaptations of the cancer survivor to a resistance training program. 3. Introduce clinicians to the resistance training programs recommendations contained in currently available guidelines and to training protocols that have been reported in the literature. Objectives 4. Describe techniques that can be used to evaluate muscle strength and power. 5. Introduce clinicians to new resistance training protocol s that might be useful in treating cancer survivors. 6. Utilize case studies to demonstrate the clinical application of material presented in this session. What is Resistance Exercise Training (RET) Strength Training or Strengthening Resistance training is a form of physical activity that is designed to improve muscular fitness by exercising a muscle or a muscle group against external resistance. Am. College of Sports Medicine (ACSM) Goals of RET in The Clinic Goal: Increase the force and the power that a muscle can generate Increased strength Improved physical functional capacity Alter body composition Improve quality of life Increase power/endurance Reduce impact of comorbidities Improve cognition 1

2 Mechanisms for Increasing Strength Increased capacity to generate energy Improved Ca +2 handling Increased amount of sarcomeric proteins Increase in muscle fiber size Increased lean body mass or muscle mass and area Fiber type changes Increased muscle protein synthesis Mechanisms for Increasing Strength Uncontrolled growth What is Cancer? Cancer Continuum Osteosarcoma Leukemia Brain Tumor Survivors Have significantly lower muscle strength than age matched healthy controls 1 RM Have less muscle mass than age matched healthy controls Lean body mass and area fat free mass Survivors Have alterations at the cellular level consistent with muscle dysfunction Reduced mitochondrial function Upregulation of muscle degradation pathways Significant reductions in muscle fiber size Fiber type changes-loss of Type IIx Reduction in numbers of satellite cells Christensen et al. Annals of Oncol. 2014:25:947 2

3 Skeletal Muscle Dysfunction and Cancer Treatment Surgery Loss and damage to muscles Compromised innervation Radiation Damage to satellite cells Fibrosis Altered cellular metabolism Chemotherapy Oxidative stress/impaired mitochondrial function Damage to satellite cells Skeletal Muscle Dysfunction 2 0 to Comorbid Conditions Sarcopenia: Frailty Cachexia Inactivity Malnutrition Cellular changes consistent with reduced function Survivors: Sarcopenia Survivors: Sarcopenia Sarcopenia: the loss of skeletal muscle mass and strength that occurs with advancing age Survivors: Sarcopenia Sarcopenia amplifies chemotherapy toxicities Sarcopenia decreases response to chemotherapy and survival RET as a counter measure Unclear Require a multimodal approach i.e. combine exercise with appropriate nutritional support Bozzeti. Annals of Oncol. 2017;28:2107 Survivors: Frailty Frailty: A medical syndrome that is characterized by diminished strength, endurance, and reduced physiologic function that increases an individual s vulnerability for developing increased dependency and/or death. Age and Ageing 2014;43: 8 9 Accelerated in cancer survivors Chronological age does not equal physiologic age 3

4 Survivors: Frailty Phenotype Unintentional weight loss > 10 pounds in prior year > 5% of body weight in prior year Weakness Grip strength in the lowest 20% at baseline Poor endurance/fatigue Self report Slowness Survivors: Frailty Phenotype Gait Speed (slowest 20% of the population) Low activity levels Self report Fried et al. J Geron: Medical Sci 2001;56A:M146 Survivors: Frailty in Cancer Survivors More than half of older cancer patients have prefrailty (2 of the 5 phenotypes) or frailty (3 or more of the frailty phenotypes) and these patients are at increased risk of chemotherapy intolerance, postoperative complications and mortality Baijal and Periyakoil. Cancer J. 2014;20:358 From: The prevalence and outcomes of frailty in older cancer patients: a systematic review. Handforth et al. Ann Oncol. 2014;26(6): doi: /annonc/mdu540 Ann Oncol The Author Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please journals.permissions@oup.com. Survivors: Inactivity From: The prevalence and outcomes of frailty in older cancer patients: a systematic review. Handforth et al. Ann Oncol. 2014;26(6): doi: /annonc/mdu540 Ann Oncol The Author Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please journals.permissions@oup.com. Mason et al. Cancer Epidemiol Bomarkers Prev. 2013; 22:1153 4

5 Survivors: Inactivity Inactivity Survivors: Inactivity Of 157 patients in a primary care clinic 10% received general advice to decrease sitting time 53% received general physical activity counselling 0% received a treatment plan for reducing sitting time Shuval et al. Br. J Sports Med. 2014;48:1451 Baumann et al. Bone Marrow Transplant. 2010;45:355 Survivors: Cachexia Characterized by severe decline in muscle mass Results from disease processes, systemic inflammation, malnutrition and activation of muscle degradation pathways Associated with advance disease It is not the equivalent of anorexia Survivors: Cachexia Symptoms Unintentional weight loss > 5% of body weight BMI < 20 for those < 65 YOA & < 22 for those > 65 Having less than 10 percent body fat An albumin level of less than 35 grams per liter (Reference Range: g/liter) There is insufficient evidence to determine the safety and effectiveness of exercise for patients with cancer cachexia. Grande et al. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No. CD010804: Intermediate Summary Cancer survivors are at risk for increased loss of muscle mass relative to age-matched healthy controls: Age Disease/treatment affects Comorbidities Inactivity Is Participation in a RET Program Safe? The results of completed studies support the safety of upper-body exercise among breast cancer survivors with and at risk for lymphedema. Training should start supervised, at a low dose, increase according to symptom response, and is likely to increase maximal and functional capacity of the affected arm. Benefits in terms of conditioning outweigh risk of developing or exacerbating lymphedema Schmitz k. Exerc Sport Sci Rev. 2010;38:17. 5

6 Is Participation in a RET Program Safe? 100 subjects; RCT; 2 subjects withdrew because of MS injuries, both conditions were pre-existing Galvo et al. Eur. Urol. 2014, 65, subjects, RCT, 3 subjects withdrew because of MS injuries Nilsen et al. Acta Oncol. (Stockh. Swed.) 2015; 54: subjects with metastatic prostate disease; RCT; 0 adverse effects during exercise sessions, withdrawals from study 5- disease progression-3, bone pain-1, fall-1 Cormie et al. Prostate Cancer and Prostatic Dis. 2013;16:328 Is Participation in a RET Program Efficacious? De Backer et al. Acta Oncologica. 2007;46:1143. Is Participation in a RET Program Efficacious? Segal et al. J Clin Oncol. 2008;27:344. Strasser et al. Med. Sci., Sports Exerc :2080. Exercise Guidelines Exercise Guidelines Adults should do muscle strengthening activities that are moderate or high intensity and involve all major muscle groups on 2 or more days a week Adults with disabilities should also do musclestrengthening activities of moderate or high intensity that involve all major muscle groups on 2 or more days a week Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely Avoid inactivity Physical Activity Guidelines Advisory Committee. Physical Activity Guidelines Advisory Committee Report, Washington, DC: US Department of Health and Human Services;

7 Exercise Guidelines Exercise Guidelines Schmitz et al. Med Sci Sports Exerc. 2010;42: Breast Cancer Start with a very low resistance Progress slowly Monitor for arm/shoulder symptoms Modify exercise program per symptoms Wear compression garment while performing exercise Little risk for exacerbating lymphedema Prostate Cancer Exercise Guidelines Recommendations are the same as age-appropriate PAG Add Pelvic floor exercises for those who undergo radical prostatectomy Be aware of fracture risk Colon Cancer Exercise Guidelines Recommendations are the same as age-appropriate PAG. Presence of a stoma: Start with low resistance Progress slowly Stoma management Exercise Guidelines-Fracture Risk Exercise Guidelines: Fracture Risk Assess for fracture risk in: Prostate cancer survivors-hormone therapy Breast cancer survivors-ai s Metastatic disease Advanced disease Assessment tools World Health Organization Fracture Risk Assessment Tool (FRAX) DXA scan-bone Mineral Density ACSM Guidelines recommends a preexercise evaluation for fracture risk in survivors on hormone therapy World Health Organization Fracture Risk Assessment Tool (FRAX) NCCN and Medicare recommend treatment for those with a 10-year hip fracture risk of at least 3% or a 10- year major osteoporosis fracture risk of at least 20%. 7

8 Fracture Risk Exercise Guidelines: Fracture Risk Other Comments Medicare covers DEXA scans Risk factor includes: age, wt. under 70 kg, prior non-traumatic fracture Prostate cancer survivors are assumed to have secondary osteosarcoma Multiple myeloma survivors should be treated as if they were osteoporotic No fracture risk level has been defined as indicating that exercise is unsafe. ACSM Guidelines Documentation: Things to Think About Generally deficient in describing components of the exercise prescription, progression of the program and adherence to the program Winters-Stone, 2014 Training period (duration of Tx plan Frequency # sets Time between sets # repetitions Time under tension Time between reps Training intensity (RPE) Borde et al. Sports Med. 2015;45:1693 Things to Think About Quantify exercise dose Composite physical activity Miller et al., Med. Sci. Sports Exerc. 2014;46:69 Things To Think About Selection biased in exercise studies The healthiest tend to complete studies 8

9 FITT PRINCIPLE FITT: Frequency, Intensity, Time (duration), Type FITT PRINCIPLE Threshold model: Achieve sufficient physiological challenge to bring about adaptive changes/training, effects, reconditioning Combining these elements (FITT) we can prescribe an adequate volume of exercise to bring about an adaptive response (reconditioning) Resistance Exercise Prescription in the Cancer Patient American College of Sports Medicine (ACSM) 1-3 times per week 50-80% 1RM or 6-12RM 1-4 sets, 6-10 exercises Exercise and Sports Science Australia 2-3 days per week 60-70% 1RM 1-3 sets of 8-12 repetitions Exercise Prescription Principles Individualization Specificity Progressive Overload Rest/Recovery Fairman CM, et al. Sports Med. 2017;47(8) Periodization The division of an annual training plan into smaller training phases, making it easier to plan, monitior, and adjust a training plan in an effort to optimize key outcomes Linear Periodization (LP) Periodization Gradual decline in volume, increase in across each mesocycle Non-Linear Periodization (NLP) More frequent alterations in intensity and Volume Fairman CM, et al. Sports Med. 2017;47(8)

10 Non-Linear Periodization Weekly Undulating Periodization (WUP) Altering the number of repetitions & training focus each week. Daily Undulating Periodization (DUP) Changing the number of repetitions & intensity each day or training session Daily Undulating Periodization (DUP) In healthy individuals Improved bench press 1RM Improved squat 1RM Upward trend for leg press 1RM Fairman CM, et al. Sports Med 2017;47(8) Exercise Prescription Principles Comparison Individualization Specificity Progressive Overload Rest/Recovery Linear Periodization Weeks x 10 (75% 1RM) Weeks x 8 (80% 1RM) Weeks x 6 (85% 1RM) Daily Undulating Periodization Monday 3 x 10 (75% 1RM) Wednesday 3 x 8 (80% 1RM) Friday 4 x 6 (85% 1RM) Autoregulation Adjust intra-training load Progress load from week to week Select a daily set and repetition scheme Leads to.. Prevent Injury Increase adherence Increase quality of life Blood Flow Restriction Pneumatic cuff that provides venous occlusion to the distal aspect of the limb. Creates an anaerobic environment at which the lower oxygen tension level allows the body to recruit muscle fibers that are normally reserved for more strenuous exercise. Upregulation of the muscle hypertrophy-signaling cascade 10

11 Blood Flow Restriction Establishing A Baseline Diminished atrophy & loss of strength Increased strength with only 30% of normal loads Increased hypertrophy with only 30% normal loads Improved muscle endurance in 1/3 the time 1 Rep Max The maximum weight that can be lifted correctly for one time Safe and reliable measurement tool Multiple Rep Max Some see this as a safer option Still provides a baseline for choosing intensity of exercise Slysz J, et al. J Sci Med Sport. 2016; 19(8): Rep Max Oddvar Holten Diagram How do we determine 1 rep max? Manually Oddvar Holten Diagram The average adult can do 10 reps at 75% of their 1RM before fatiguing 1 Rep Max Essentials of Strength Training and Conditioning 11

12 1 Rep Max vs. Multi Rep Max Rating of Perceived Exertion Essentials of Strength Training and Conditioning RPE & Repetitions in Reserve During or upon completion of a set the patient records an REP which corresponds to an RIR 10 RPE = 0 RIR 9 RPE = 1 RIR 8 RPE = 2 RIR And so on. STRENGTH: METHODS OF ASSESSMENTS Hand held dynamometer Isokinetic machines Fairman CM, et al. Sports Med 2017;47(8) Summary Cancer survivors have less than optimal strength for a number of reasons. This adds to the symptom burden experienced by survivors. Participation in RET is both safe and efficacious. Collectively, participation in a RET program should be a part of a comprehensive physical therapy treatment plan for a cancer survivor. Thank you for the privilege of the podium 12